Text 13. Eating disorders Read the text and answer the question: What are the main types of eating disorders?

Eating is controlled by many factors, including appetite, food availability, family, peer, and attempts at voluntary control.

Researchers are investigating how and why such behaviors as eating smaller or larger amounts of food than usual, move beyond control in some people and develop into an eating disorder. Eating disorders are not due to a failure of will or behavior; rather, they are real, treatable medical illnesses.

The main types of eating disorders are anorexia nervosa and bulimia nervosa. A third type, binge-eating disorder, has been suggested but has not yet been approved as a formal psychiatric diagnosis. Eating disorders frequently develop during adolescence or early adulthood, but their onset can occur during childhood or later in adulthood.

Eating disorders frequently co-occur with other psychiatric disorders such as depression, substance abuse, and anxiety disorders. In addition, people who suffer from eating disorders can experience a wide range of physical health complications, including serious heart conditions and kidney failure which may lead to death. Recognition of eating disorders as real and treatable diseases, therefore, is very important.

Females are much more likely than males to develop an eating disorder. Only 5 to 15 percent of people with anorexia or bulimia and an estimated 35 percent of those with binge-eating disorder are male.

Anorexia nervosa. An estimated 0.5 to 3.7 percent of females suffer from anorexia nervosa in their lifetime. Symptoms of anorexia nervosa include:

• Resistance to maintaining body weight at or above a minimally normal weight for age and height

• Intense fear of gaining weight or becoming fat, even though underweight

People with this disorder see themselves as overweight even though they are dangerously thin. The process of eating becomes an obsession. Unusual eating habits develop, such as avoiding food, picking out a few foods and eating these in small quantities, or carefully weighing food. People with anorexia may repeatedly check their body weight, and many engage in other techniques to control their weight, such as intense and compulsive exercise, or purging by means of vomiting and abuse of laxatives, enemas, and diuretics.

The mortality rate among people with anorexia has been estimated at 0.56 percent per year, or approximately 5.6 percent per decade, which is about 12 times higher than the annual death rate due to all causes of death among females ages 15–24 in the general population.

Bulimia nervosa. An estimated 1.1 percent to 4.2 percent of females have bulimia nervosa in their lifetime. Symptoms of bulimia nervosa include:

• Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating

• Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting or misuse of laxatives, diuretics, enemas, or other medications (purging); fasting; or excessive exercise

• The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months

• Self-evaluation is unduly influenced by body shape and weight

Because purging or other compensatory behavior follows the binge-eating episodes, people with bulimia usually weigh within the normal range for their age and height. However, like individuals with anorexia, they may fear gaining weight, desire to lose weight, and feel intensely dissatisfied with their bodies.

Binge-eating disorder. Between 2 percent and 5 percent of Americans experience binge-eating disorder in a 6-month period. Symptoms of binge-eating disorder include:

• Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating

• The binge-eating episodes are associated with at least 3 of the following: eating much more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not feeling physically hungry; eating alone because of being embarrassed by how much one is eating; feeling disgusted with oneself, depressed, or very guilty after overeating

• Marked distress about the binge-eating behavior

• The binge eating occurs, on average, at least 2 days a week for 6 months

• The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise)

People with binge-eating disorder experience frequent episodes of out-of-control eating, with the same binge-eating symptoms as those with bulimia. The main difference is that individuals with binge-eating disorder do not purge their bodies of excess calories. Therefore, many with the disorder are overweight for their age and height. Feelings of self-disgust and shame associated with this illness can lead to bingeing again, creating a cycle of binge eating.

Treatment strategies. Eating disorders can be treated and a healthy weight restored. The sooner these disorders are diagnosed and treated, the better the outcomes are likely to be. Because of their complexity, eating disorders require a comprehensive treatment plan involving medical care and monitoring, psychosocial interventions, nutritional counseling and, when appropriate, medication management. At the time of diagnosis, the clinician must determine whether the person is in immediate danger and requires hospitalization.

Treatment of anorexia calls for a specific program that involves three main phases: (1) restoring weight lost to severe dieting and purging; (2) treating psychological disturbances such as distortion of body image, low self-esteem, and interpersonal conflicts; and (3) achieving long-term remission and rehabilitation, or full recovery. Early diagnosis and treatment increases the treatment success rate. Use of psychotropic medication in people with anorexia should be considered only after weight gain has been established. Certain selective serotonin reuptake inhibitors (SSRIs) have been shown to be helpful for weight maintenance and for resolving mood and anxiety symptoms associated with anorexia.

The acute management of severe weight loss is usually provided in an inpatient hospital setting, where feeding plans address the person’s medical and nutritional needs. In some cases, intravenous feeding is recommended. Once malnutrition has been corrected and weight gain has begun, psychotherapy (often cognitive-behavioral or interpersonal psychotherapy) can help people with anorexia overcome low self-esteem and address distorted thought and behavior patterns. Families are sometimes included in the therapeutic process.

The primary goal of treatment for bulimia is to reduce or eliminate binge eating and purging behavior. To this end, nutritional rehabilitation, psychosocial intervention, and medication management strategies are often employed. Establishment of a pattern of regular, non-binge meals, improvement of attitudes related to the eating disorder, encouragement of healthy but not excessive exercise, and resolution of co-occurring conditions such as mood or anxiety disorders are among the specific aims of these strategies. Individual psychotherapy (especially cognitive-behavioral or interpersonal psychotherapy), group psychotherapy that uses a cognitive-behavioral approach, and family or marital therapy have been reported to be effective. Psychotropic medications, primarily antidepressants such as the selective serotonin reuptake inhibitors (SSRIs), have been found helpful for people with bulimia, particularly those with significant symptoms of depression or anxiety, or those who have not responded adequately to psychosocial treatment alone. These medications also may help prevent relapse. The treatment goals and strategies for binge-eating disorder are similar to those for bulimia, and studies are currently evaluating the effectiveness of various interventions.

People with eating disorders often do not recognize or admit that they are ill. As a result, they may strongly resist getting and staying in treatment. Family members or other trusted individuals can be helpful in ensuring that the person with an eating disorder receives care and rehabilitation. For some people, treatment may be long term.

TEXT 14. FEARS AND PHOBIAS

Read the text and find out the difference between fears and phobias.

What is fear? Fear is a normal human emotional reaction – it is a built-in survival mechanism with which we are all equipped. Even as babies, we possess the survival instincts necessary to respond when we sense danger. Fear is a reaction to danger that involves the mind and body. Fear serves a protective purpose – signaling us of danger and preparing us to deal with it.

A fear reaction happens whenever we sense danger or when we’re confronted with something new or unknown that seems potentially dangerous. Fear can be brief – like the startled reaction you have if a balloon unexpectedly pops or if you are surprised by something you didn’t expect. This is often over in seconds, as soon as the brain gets enough data to realize there’s no danger. If the brain doesn’t receive the "all clear" signal, fear can last longer and feel more intense.

Most people tend to avoid the things they feel afraid of. There are, of course, exceptions – some people seek out the thrill of extreme sports, for example, because the rush of fear can be exciting. We all experience fear slightly differently and with more or less intensity. Some people even like it and find it exciting.

Children tend to have more fears than adults because so much of what they experience is new and unfamiliar. Older children tend to have different fears than younger children, but it’s normal for kids to have at least a handful of things that are scary to them. Whereas young children tend to fear things like the dark, monsters, loud thunder and lightning, getting lost, or big dogs, older kids are more likely to fear things like being bullied or getting hurt.

Teens have certain common fears, too. Most teens have some social fears like the fear of being embarrassed or rejected or fear of failing. They may also have personal fears, such as a fear of becoming ill or injured. Some may feel afraid of heights, dogs, snakes, or insects or of performing or public speaking. Because teens think about and care about the larger world community, they may also have global fears such as a fear of war or violence.

Some normal fears seem pretty much like a worry, or something you feel generally afraid of or uneasy about. Other times, fear comes as a sudden reaction to a sudden confrontation with danger. It’s that sudden fear response that triggers the body’s survival mechanism known as the fight or flight reaction. The fear reaction is known as "fight or flight" because that is exactly what the body is preparing itself to do – to fight off the danger or to run like crazy to get away.

What’s happening in the body when you experience this reaction? The brain triggers a response that causes the heart rate to increase, blood to pump to large muscle groups to prepare for physical action (such as running or fighting), blood pressure to increase, skin to sweat to keep the body cool, and so forth. The body stays this way until the brain signals that it’s safe to relax.

What`s the difference between fear and anxiety? Fear is a reaction to an actual danger signal – it involves physical and mental tension that helps you spring into action to protect yourself from something that is happening. The body suddenly gears up into fight or flight mode when, for example, the car in front of you swerves and you just miss it. Once you know the danger has passed, the fear goes away (though your knees may feel shaky for a few minutes).

The physical and mental tension of anxiety is very similar to fear but with one important difference. With anxiety, there isn’t usually anything actually happening right then and there to trigger the feeling. The feeling is coming from the anticipation of future danger or something bad that could happen – there is no danger happening now.

Everyone experiences anxiety from time to time. It can be mild or intense or somewhere in between. A little anxiety helps us to stay on our toes and motivates us to do our best. For example, some anxiety about the possibility of doing poorly on a test can motivate you to study a little harder. A moderate amount of anxiety helps the body and mind get prepared to cope with something stressful or frightening.

Sometimes anxiety can get out of proportion and become too intense or too lasting, and it can interfere with a person’s ability to do well. Teens who have a pattern of experiencing too much anxiety may be diagnosed with an anxiety disorder. There are several types of anxiety disorders a teen might experience - each type is named for the symptoms a teen might have or the particular way that anxiety affects him. Many teens with anxiety problems have symptoms that overlap into more than one category.

What is a phobia? A phobia is an intense, unreasonable fear of a thing or a situation. The fear and distress lead the person to avoid the object or situation they fear. If a person is afraid to jump from an airplane, he’ll probably always avoid signing up for skydiving lessons. One could argue that this fear is somewhat reasonable and that skydiving is actually a risky activity. And not skydiving probably won’t interfere much with the person’s life. But if a phobia is related to an everyday object or situation, steering clear of it would cause greater disruption in someone’s life. And if that fear is unreasonable – that is, most people would agree that there’s not actually much danger – then the fear would probably be considered a phobia.

With a phobia, a person’s fear is so intense that they do whatever they can to avoid coming into contact with the object of their fear, and often spend time thinking about whether they’re likely to encounter it in a given situation. For a fear to be considered a phobia it has to be so extreme and cause so much distress that it gets in the way of a person’s normal activities.

Phobias interfere with a person’s life because the need to avoid the object of the phobia limits what what a person feels comfortable doing. A teen with a phobia of dogs, for example, may avoid going to friends’ homes because they have dogs or to the park because there might be a dog there. So although it may be totally normal for a teen to be somewhat afraid of a large growling dog he doesn’t know, a teen with a phobia of dogs may be so fearful that seeing any dog is very frightening and merely thinking about encountering a dog might be distressing.

What causes phobias? Some people may be more likely to develop phobias than others. Anxiety problems often run in families, and a phobia is one type of anxiety problem. Kids and teens who tend to be fearful and who worry a lot often have parents who have these traits. Anxiety that runs in families can partly be explained by biology and genetics. Certain biological traits passed down in families may affect the brain’s chemical regulation of mood and can affect how sensitive someone is or how strongly they react to fear cues.

Some people are born with a natural tendency to be more cautious and inhibited; others have an inborn tendency to be more bold and uninhibited. Having a cautious style may make it more likely for someone to develop phobias or anxiety.

Learning also plays a role in helping phobias develop and linger. Children learn by watching how their parents and others react to the world around them – this is part of how kids learn what’s safe and what’s dangerous. If parents are overcautious or overemphasize danger, children may more easily learn to see the world this way, too.

When someone develops a phobia, they quickly learn that they feel anxious when they are near the object or situation they fear – and that they feel relief when they avoid it. Learning that avoidance can reduce their anxiety (at least for the moment) and increase the likelihood, that they will avoid the feared situation or object next time. The difficulty is that these avoidance behaviors have to keep increasing and happening even sooner to provide the same relief. Pretty soon, a person finds himself spending time worrying about the possibility of encountering the feared situation and avoiding anything that might bring him into contact with it. With a phobia, the pattern of anxiety, avoidance, and worry about the possibility of contact tends to grow bigger and interferes more with life over time.

What are specific phobias? The term specific phobia is used for an intense unreasonable fear of a specific object or situation. Someone may have a specific phobia of snakes, heights, elevators, or blood, for example.

Specific phobias may develop when a person has an encounter with an object or situation that involves or provokes fear. A brain structure called the amygdala, which keeps track of memory and emotions, remembers when that person encounters the object the next time that it provoked fear in the past. The amygdala then signals that the object might be dangerous.

How are specific phobias treated? Gradual exposure to the object or situation is a very effective way to help people overcome specific phobias. Exposure is a technique based on certain principles of learning and behavior. The idea is that the brain can learn to adapt to something that seems dangerous at first, but isn’t actually dangerous, by gradually having time to encounter that thing in a controlled, gradual, supported way. Just as kids can learn to overcome their fear of the dark by gradually getting used to it with the right support and reassurance of safety, gradual exposure can introduce someone slowly to the feared object or situation, allowing the brain to adjust. With this gradual exposure, anxiety decreases as the person faces the fear - first from a distance, then gradually closer and more fully. Exposure may even begin by having the person simply imagine the object or look a picture of it because with phobias this can be enough to trigger the intense fear.

Exposure is usually combined with techniques that help people to relax while they are imagining or encountering the object. Relaxation techniques may include things like specific ways of breathing, muscle relaxation training, guided mental imagery, or soothing self-talk. Pairing a relaxing sensation with an object that has triggered fear can help the brain to neutralize the fear the object used to be associated with.

TEXT 15.  INSOMNIA

Read the text and answer the question: What are the causes of insomina?

The definition of insomnia, according to the American Sleep Disorders Association (ASDA), is difficulty falling asleep or staying asleep. If it occurs every night or most nights for an extended time, it’s called chronic insomnia.

According to ASDA estimates more than 35 million Americans suffer from this long-lasting type of insomnia with 20 to 30 million others suffering shorter-term sleeplessness. Men and women of all ages experience insomnia, but it is more common in the elderly and in women, especially after menopause. The consequences of a "Sleepless Society" can be serious.

Like a headache or fever, insomnia may be a symptom of another problem. It can result from a stressful event like a test or meeting, or from a longer-lasting stressful circumstance, such as a sick child or troubled marriage. Even worrying about having a tough time falling asleep may itself prevent a person from drifting off.

Other common causes of nighttime wakefulness include environmental disturbances, such as noise from traffic or television, an uncomfortable temperature, or light from the sun or other source; use of alcohol or stimulants, such as caffeine or nicotine; and erratic hours, like those of shift workers and people whose air travel takes them across time zones.

Sometimes short-term insomnia may go away on its own or with simple changes in daytime or sleep-time habits. If these lifestyle changes don’t work, the careful use of sleeping pills approved by the Food and Drug Administration may help provide temporary relief from insomnia.

A doctor can help choose an appropriate medicine. One factor to consider is the drug’s half-life, or the time it takes to be cleared from the body. Drugs with shorter half-lives are less likely to have carry-over sedation that affects daytime functioning.

A second factor is the drug’s toxicity. Because of their lower risk of overdose, the newer benzodiazepines and benzodiazepine-like drugs are used more often to treat insomnia than barbiturates and other older drugs. Among the most commonly prescribed benzodiazepine sleep-aids are flurazepam (Dalmane), estazolam (ProSom), quazepam (Doral), temazepam (Restoril), and triazolam (Halcion).

As a rule, these sleeping pills should be used only for short periods because of the risk of developing dependency and withdrawal symptoms when the drugs are stopped. So, while they may help with short-term insomnia induced by jet lag, shift work schedule changes, or short-term stress, they should generally not be used for chronic insomnia because of their potential addictiveness and because they can mask underlying medical problems.

Some other sleep-aids are available without a prescription, including diphenhydramine and doxylamine. These products contain a sedating antihistamine and, like prescription drugs, must be used with care. Even if taken at night, they can cause daytime drowsiness, which can make driving and other tasks risky.

Sleep Apnea: more than simple snoring. Unlike short-term sleeplessness, chronic insomnia is often a symptom of a serious underlying medical disorder. Depression and other psychiatric disorders account for many cases of insomnia, as do wholly physical illnesses, such as asthma, arthritis, Parkinson’s disease, kidney or heart disease, and hyperthyroidism.

Sleep apnea is among the most common and most dangerous types of sleep disorder. An estimated 18 million Americans have the condition, which is marked by repeated episodes of cessation of breathing during sleep that over time can lead to high blood pressure, cardiac disease, and disordered thinking.

Obstructive sleep apnea is by far the most common type. Breathing is interrupted when air can’t flow into or out of the nose or mouth. The reason for the blockage could be an over-relaxation of the throat muscles and tongue, which partially blocks the airway or, in obese people, an excess amount of tissue in the airway. Those with receding chin lines are also at higher risk for developing obstructive sleep apnea.

In the less common form, central sleep apnea, breathing is stopped not because the airway is closed but because the diaphragm and chest muscles stop working.

Mild cases of obstructive sleep apnea can sometimes be treated by making simple behavioral changes, such as avoiding alcohol, tobacco, and sleeping pills; losing weight; and sleeping on one’s side. Also, oral devices to prevent obstruction of the airway by holding the tongue or jaw forward may help with mild cases.

The most common effective treatment for obstructive sleep apnea is nasal continuous positive airway pressure, or CPAP. The patient wears a soft plastic mask over his or her nose while sleeping. A device supplies pressurized room air through a flexible tube attached to the mask. The pressurized air acts as a splint to prevent the airway from collapsing.

Surgery to increase the size of the airway is another possible option for sleep apnea treatment. The removal of adenoids and tonsils, especially in children, or other growths or tissue in the airway is sometimes effective, as are other, relatively more risky surgical procedures, including uvulopalatopharyngoplasty (shaving of the excess soft tissues in the mouth and throat) and tracheotomy (creating an opening in the neck through the windpipe) for the most severe cases.

The newest device for this condition is Somnoplasty, used to treat mild cases of sleep apnea. It is a radio frequency surgical device that shrinks the soft palate in a half-hour outpatient procedure. FDA approved the Somnoplasty device in July 1997.

When to worry. Just as snoring isn’t always a sign of dangerous apnea, neither is a sleepless night or two necessarily a medical emergency. Sometimes sleep patterns differ based on simple factors like age and lifestyle.

Bob Rappaport, M.D., a sleep medicine specialist, neurologist encourages people to consider getting help if their sleeplessness persists and appears to be unrelated to life circumstances.

Sleep specialists provide some tips to help you reach dreamland:

• Avoid caffeine (including caffeine-containing drugs), nicotine, and alcohol for four to six hours before bedtime. The first two are stimulants that can make it difficult to sleep. And while alcohol may have a sedating effect at first, it tends to disturb sleep after several hours.

• Don’t exercise within four to six hours of bedtime. Working out earlier in the day, though, not only doesn’t hinder sleep, but can actually improve it.

• Perform relaxing rituals before bed, such as taking a warm bath, listening to relaxing music, or eating a light snack.

• Before going to bed, try to put your worries out of your mind and plan to address them another time.

• Reserve your bed for sleeping. To preserve the association between bed and slumber, don’t watch television or do work in bed.

• Go to bed only when sleepy. If you can’t fall asleep within 15 to 20 minutes, get out of bed and read a book or do another relaxing activity for awhile, rather than trying harder to fall asleep.

• Make sure your bed is comfortable and the bedroom is conducive to restful sleep – quiet and at a comfortable temperature, for example.

• Wake up about the same time every day, even on weekends, to normalize the sleep-wake schedule.

• Don’t take naps, or nap during the mid-afternoon for no more than 30 minutes.

Melatonin. Many Americans in search of more satisfying slumber are buying the hormone melatonin at their local health food stores. Melatonin-containing products are marketed as dietary supplements, which can be sold without FDA’s premarket review or approval. Researchers caution melatonin users about the absence of scientific studies to prove that melatonin is safe and helpful in treating insomnia.